Part 1—Suggestion:
Suggestion is the psychological process whereby the thoughts, feelings, behavior, and perception of a subject are affected by influences such as verbal guidance. Suggestion is sometimes referred to “waking suggestions” because they are given in the absence of hypnosis. Suggestion can produce strong changes in perceptual experience and are given in precisely the same way as “hypnotic suggestions” (i.e., suggestions given within hypnosis). Early researchers such as Hull conducted experiments on suggestion [1]. More recently, experiments investigating suggestion were conducted by researchers such as Nicholas Spanos and Irving Kirsch, revealing strong correlation between people's responses to suggestion both in and outside hypnosis [2]. Although suggestion does not rely on a subject being under hypnosis in order to effect change, suggestion is considered one of the two primary components of a formal hypnotic experience.
Part Two—Hypnosis:
Hypnosis is a state of inner absorption, concentration and focused attention. Hypnosis can be thought of consisting of two primary components: trance and suggestion. [3]. Recent research supports the view that hypnotic suggestions and visualization effectively changes aspects of the person's physiological and neurological functions.
When using hypnosis, the subject is guided to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought, or behavior. If the subject responds to hypnotic suggestions, it is generally inferred that hypnosis has been induced. Many believe that hypnotic responses and experiences are characteristic of a hypnotic state.
Details of hypnotic procedures and suggestions will differ depending on the goals of the practitioner and the purposes of the clinical or research endeavor. Procedures traditionally involve suggestions to relax, though relaxation is not necessary for hypnosis and a wide variety of suggestions can be used including those to become more alert. Suggestions that permit the extent of hypnosis to be assessed by comparing responses to standardized scales can be used in both clinical and research settings. Further, hypnosis does not require that the subject's eyes be closed.
Clinical hypnosis is an altered state of awareness, perception or consciousness that is used, by licensed and trained doctors or masters prepared individuals, for treating a psychological or physical problem. It is a highly physically relaxed and mentally focused state. Practitioners using clinical hypnosis encourage the use of imagination, as mental imagery is very powerful, especially in a focused state of attention.
Mental imagery, mental rehearsal, and visualization are terms that can be used to describe an experience that resembles a real world scenario without actually being in that real world. All three can include “audio” as a component of the overall experience. Mental imagery has been described as holding within one's mind a vivid representation of a task as if it had already happened. The theory underlying mental rehearsal suggests that when we mentally 550174.1 image a motor behavior we are creating neural patterns of the accurate task we intend to perform [35, 36]. Mental imagery can be used to improve confidence, problem solve, reduce anxiety, and improve performance of a motor task. Additionally, it has been used in a variety of fields such as the arts, sports, business, alternative medicine and psychology. For example, Olympic divers may “visualize” themselves performing a dive without ever entering the water. Studies show that motor imagery and motor performance possess similar neural substrates [37]. Mental imagery has also been shown to be effective in motor rehabilitation and has potential as a cognitive strategy for functional recovery from stroke [4,38-43].
A subject's ability to engage with mental imagery can be enhanced when under hypnosis. Research shows that using imagery while under hypnosis, even if only symbolic, assists in bringing about the things being imagined. In the medical field, hypnosis is used to reduce side effects of medical procedures, reduction and control of pain, control of bleeding, and accelerate healing, among other medical applications.
Part 3—Mirror Neuron System:
Mirror neuron activity was discovered in the 1990's through brain imaging technologies. It was discovered that certain brain cells in the frontal lobe premotor cortex activate when humans and primates perform actions such as reaching for something or pulling a lever. These brain cells are called the motor command neurons [12, 13]. It was discovered that a subset of these motor neurons were activated when a human or primate watched someone other than themselves perform the same action [6, 10]. Located in the fronto-parietal region of the brain, this subset is referred to as the mirror neuron system [14].
Visual interventions using human or other stimulus focus have been incorporated in investigations of the mirror neuron system. These visual interventions have employed both video and virtual reality [8, 9]. Living characters performing real world, everyday tasks being recorded on video is one of the most common approaches. Examples of this include the recording of mirror neuron activation when human subjects watched videotapes of forms of communication including humans talking, dogs barking, and an ape's pursed lips [10]. Mirror neuron activity was provoked only when watching the video of humans talking. This suggests that content of the visual stimulus must be relevant and relatable to humans in order to activate the human mirror neuron system. Noted here is the fact that the video is of someone other than the viewer is performing the task.
The mirror neuron system becomes active when we move, when we observe another person moving to perform a task (action-observation), and also when we intend to move (observation with intent to imitate). When observation and movement are combined there is a greater response in the mirror system than when either is performed alone [19]. Also, research has shown the importance of sense of self and purpose when engaging the human mirror neuron system. It has been shown that one observing an effector results in the activation of their mirror neuron system, and that the type of effector and relationship to the observer has a significant impact on the level of mirror neuron activity, as well as be a determining factor on the observer's ability to interpret inferred motion. When observers cannot interpret inferred motion, for example in the case of a robotic effector (machine arm/hand) [18], the mirror neuron system is least active. When observing a human effector (human arm/hand) and is able to interpret inferred motion, the observer's mirror neuron system becomes more active. Mirror neuron activity increases with the ability to interpret inferred motion increases. This occurs when an observed human effector performs an action that represents receiving or gaining something, such as drinking a cup full of tea. Mirror neurons are activated less when the human effector has the goal of merely performing an action, such as cleaning the empty tea cup [8]. It has also been discovered that individuals with autism show increased mirror neuron system response when they observe a familiar person rather than a stranger performing a movement, and an even greater mirror neuron response when they observe themselves perform a movement [11]. These findings demonstrate the importance of sense of self and purpose when engaging the human mirror system.
It is believed the mirror neuron system [15-17] may represent the underlying neurophysiological substrate for therapeutic intervention based on action-observation-intention. Action observation has been shown to enhance physiological motor rehabilitation [5]. Further, intention is an important component of physiological motor rehabilitation—the intention of the individual to move their impaired limb [7]. For example, in a stroke patient, a set of neurons that form the basis for movement generation may be subserved through the patient observing movements, imagining movements and attempting through intention to perform task specific movements. A recent study demonstrated that action observation combined with physical practice congruent with the action observed, can enhance the effects of motor training after stroke [20].
Mirror neuron system activation engaged through purpose and self, observation, and intention, can be facilitated and optimized through the methods of the present invention, and can be applied to motor rehabilitation, as well as to the areas involving transformation, training, or learning.
Part 4—Virtual Reality:
Virtual Reality (VR), as applied to computer simulated environments, provides physical presence to users through the display of virtual environments. VR presentations are typically presented on a computer screen, a video display, or a head-mounted display (HMD), and can be presented in 2D, 3D, or stereo 3D. VR environments are typically visual experiences, however other forms of sensory information such as sound, and tactile information, such as haptics that provide user input to the VR application or force-feedback to the user, are also utilized in the experience. The VR environment can simulate an imaginary environment, as in VR games, or the real world as a lifelike experience, such as combat or medical simulations. VR allows the participant to enter a simulated world through multi-modal sensory feedback, and has been used for the training of motor tasks involving highly complex activities such as surgical techniques [21], flight simulation [22], and military exercises [23].
VR has recently been used in a therapeutic role in various forms. One area of therapeutic VR is exposure therapy, such as in phobia treatments, addiction, and treating PTSD. In treating phobia, VR can provide exposure to a phobic experience through a virtual environment that represents a true exposure. For addiction, VR is used to provide a virtual environment that provides cues to the addictive substance in a social setting. Recently, the U.S. Navy piloted a treatment based upon a video game developed using a real time VR game engine that consisted of a relatively complex simulation of urban combat settings that was used to immerse veterans suffering from PTSD. For phobia, PTSD, and addiction, exposing the patient to their fear, trauma, or source of addiction through VR based simulation leads to desensitization to the associated experience and results in a significant reduction in symptoms.
Other therapeutic fields that research is being conducted on the use of VR include rehabilitation, physical therapy, and occupational therapy. One example of adult rehabilitation involves patients in the chronic phase following stroke suffering from the resultant neurological dysfunction. The VR intervention applied to these patients focused on retraining faulty movement patterns and augmenting rehabilitation of the upper limb [24,25]. VR has also been used for lower limb motor rehabilitation in stroke patients.
Substantial effort and expertise has been focused on developing these innovative technology based interventions to exploit the neuroplastic properties associated with the sensorimotor systems in the adult brain. Specifically, these efforts have investigated the use of robotics, virtual reality computer games, intensive therapeutic exercise such as Constraint Induced Movement Therapy (CIMT), Accelerated Skill Acquisition Program (ASAP), and mental practice [26-31]. While most current studies are laboratory based, expensive, and have used small sample sizes, promising trends have been established for improving hand function [24,25,32] and locomotor activity [33] in individuals with chronic stroke. Gains achieved through practice in virtual environments have been shown to carry over in real-world activity, sometimes resulting in functional improvement in activities of daily living [24, 32].
There are fundamental and dramatic advantages inherent in the use of VR approaches for treating cognitive, motor, and behavioral impairments in individuals post stroke. VR offers an ideal core technology because it allows for the creation of computer generated 3D simulations, within which hierarchical task relevant challenges can be delivered and titrated across a range of difficulty levels [34].
In this way, an individual's treatment plan can be customized to begin at a stimulus level that is appropriate and focused on their goals. VR allows for the presentation of more ecologically relevant stimuli that are embedded in meaningful and familiar contexts. By designing VR environments that not only “look like” the real world, but actually incorporate challenges that require “real world” functional behaviors, the ecological validity of cognitive/motor interventions can be enhanced and return to work is more likely. Within such simulations, the complexity of stimulus challenges found in naturalistic settings can be delivered while still maintaining the experimental control required for rigorous scientific analysis and replication.
Part 5—Augmented Reality:
One definition of Augmented Reality (AR) is an experience of a live view of a real world environment in real time through a viewing component connected to a computer that augments elements of the real world environment by overlaying virtual content over the real world environment. Overlays may be positioned relative to the real world elements in one of several ways, including orientation and positioning tracking facilitated by GPS, gyroscopes, and accelerometers, or computer vision pattern recognition that reads patterns on paper or similar that are placed on particular real world environment elements and are the target for augmented virtual overlays. A more advanced form of computer vision pattern recognition involves recognizing objects themselves. Overlays may be 2D or 3D objects, animated characters, or text-based information, among other things.
AR is still in its infancy relative to the other technologies mentioned here. This is particularly true in rehabilitation, transformation, training, and learning.
Part 6—Video:
Different forms of video have been used for many years in the areas of rehabilitation, transformation, training, and learning. Videos of actors performing specific motion have been used to engage the mirror neuron system in efforts to assist in the rehabilitation of stroke patients. In cases where video records live motion in real time for playback at a later time, a stroke patient cannot get a video of themselves performing the prescribed motion that would be used to assist in their rehabilitation.